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REUTERS: Healthier sides and drinks were added to U.S. fast-food restaurant kids' menus in the past decade, but healthy combinations are still rarely offered as the default option, researchers say.

"For a lot of families, eating out is a regular option for meals, rather than an occasional treat," said lead author Megan Mueller, a researcher at the UCLA Fielding School of Public Health in Los Angeles. Children consume about 150 extra calories on days when they eat out, and healthier sides and drink choices could counteract that, she added.

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"Since restaurant meals are generally less healthy than meals prepared at home, it's important to consider ways to make it easier for families to eat healthy when eating out," she told Reuters Health by email.

Mueller and colleagues analyzed a national commercial database of restaurant menus to assess changes in side-dish and drink options on children's menus at 20 popular fast food chains between 2004 and 2015. They looked for both the number of healthy options that became available during that period, as well as the proportion of meal combinations that included healthy choices as an option or by default.

Both regular and diet sodas and flavored milk were included in the unhealthy "sugary" drink category, and 100-percent fruit juices were included in the non-sugary drink category.

Overall, researchers found, meal bundles that included at least one fruit and non-fried vegetable as an option increased by nearly 58 percentage points between 2004 and 2015, from less than one quarter of bundles to about 80 percent of them. Meal bundles with the healthier option as a default rose from zero in 2011 to nearly 20 percent in 2015.

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Bundles with healthier drinks as an option rose from roughly half in 2004 to about 80 percent in 2015, when some 20 percent of bundles had the healthier drink choice as a default, up from about 5 percent in 2011.

Of the 20 chains examined, 30 percent offered healthier choices as the default option in their meal bundles by 2015, the study team reports in the American Journal of Public Health.

"It was surprising to see how much progress these restaurants made in offering healthier sides and beverages as options in children's meals, but how much more progress still needs to be made in offering these healthier items by default," Mueller said.

The researchers now want to understand the best ways to encourage restaurants to offer more healthy options by default. Several cities, including Baltimore, Maryland, and Long Beach, California, have moved in this direction by requiring restaurants to offer certain healthy options automatically, she added.

"Offering healthy defaults is critical, not only because defaults influence what we ultimately choose, but because it teaches kids that soda is not a normal beverage to drink with a meal," said Alyssa Moran of the Johns Hopkins Bloomberg School of Public Health in Baltimore, who wasn't involved with the study.

"With healthy defaults, implementation is key," she said in an email. "While restaurants may change what is offered on their menu boards, unhealthy options may still be offered at the register or advertised more heavily."

The recent trend of calorie labeling may encourage restaurant chains to change the overall composition of meal bundles to display lower calorie items, Mueller's team writes. More information about nutrients in the meals could help parents and kids make better choices, too.

"Although healthy changes to the beverages and sides on the children's menu is a positive trend, the vast majority of children do not eat from the children's menu," said Sara Bleich of the Harvard T.H. Chan School of Public Health in Boston, who wasn't involved in the study, researches nutrient composition of adults' and kids' menus in U.S. chain restaurants.

"To meaningfully promote healthier eating, it is critical to encourage and track changes across the entire menu," she said in an email.

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